Provider Demographics
NPI:1144060476
Name:THERAPEUTIC WELLNESS LLC
Entity type:Organization
Organization Name:THERAPEUTIC WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:QUINTARA
Authorized Official - Middle Name:
Authorized Official - Last Name:HICKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-809-9024
Mailing Address - Street 1:14420 MARITIME DR
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:SC
Mailing Address - Zip Code:29720-0256
Mailing Address - Country:US
Mailing Address - Phone:919-809-9024
Mailing Address - Fax:
Practice Address - Street 1:14420 MARITIME DR
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:SC
Practice Address - Zip Code:29720-0256
Practice Address - Country:US
Practice Address - Phone:919-809-9024
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-24
Last Update Date:2024-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty